<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202706
Report Date: 11/23/2024
Date Signed: 11/23/2024 04:49:26 PM

Document Has Been Signed on 11/23/2024 04:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME:AEGIS ASSISTED LIVING OF APTOSFACILITY NUMBER:
445202706
ADMINISTRATOR/
DIRECTOR:		GALVAN, GRISELDAFACILITY TYPE:
740
ADDRESS:125 HEATHER TERRACETELEPHONE:
(831) 684-2700
CITY:APTOSSTATE: CAZIP CODE:
95003
CAPACITY: 100CENSUS: 79DATE:
11/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:55 PM
MET WITH:Jose ColimoteTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Albert Johnson conducted a case management visit on today's date for a health and safety deficiency found during the tour of the facility

The following deficiency was observed by staff and LPA:
  • Unlocked toxins under the sink in the memory care unit. The cabinet has a locking devise, however, it is broken and unable to be locked. The toxin were accessible to the four resident seated in the dining area unsupervised. There are 12 resident in the memory care area and two staff working on this date.


Deficiency cited on the following 809-D to Title 22 regulations.

Exit interview conducted and appeal rights discussed and given.

A copy of this report was left with the Lead/
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/23/2024 04:49 PM - It Cannot Be Edited


Created By: Albert Johnson On 11/23/2024 at 04:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA

FACILITY NAME: AEGIS ASSISTED LIVING OF APTOS
FACILITY NUMBER: 445202706

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/25/2024
Section Cited
CCR
87705(f)(2)

1
2
3
4
5
6
7
87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
1
2
3
4
5
6
7
Administrator shall submit a plan to Licensing on how toxins will be locked up in facility and provide toxin training to maintenance staff or any other staff responsible for cleaning.
8
9
10
11
12
13
14
This requirement was not met as evidenced by observation and photo taken there was unlocked toxins under the sink in the memory care unit. This is an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Licensee shall submit curriculum and date of training to Licensing by 11/25/2024. If additional time is needed please request additional time by POC date via email provided on LPA's busniess card.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2